It is not uncommon for health plan participants to express confusion about the pre-existing condition exclusion. Many times, a participant mistakenly thinks that a claim has been denied when the plan is simply looking for clarification. The A-Plus Benefits Employee Medical Plan, like many other group policies, contains a one year exclusion on conditions which are considered by the plan to be pre-existing.

Pre-existing conditions exist when an employee or dependent has an illness or injury for which medical advice, care or treatment (including prescribed drugs or medicine) was recommended or received during the six months prior to the coverage start date or prior to the first day of the employee’s waiting period (whichever is earlier).

It is possible to reduce or eliminate the waiting period if a participant (and dependents) has had prior heath insurance coverage without a gap of more than 62 days from the last date of coverage to the first day of the employee’s waiting period. Upon termination of prior coverage, a Certificate of Creditable Coverage (HIPAA Certificate) should be sent to a participant. If the certificate is not automatically sent, one can be easily requested from the prior insurer. This certificate is the best way to provide proof to the A-Plus Benefits plan that prior coverage existed. If the participant had 12 months of continuous prior coverage, the participant can waive all of the waiting period. If the participant has fewer than 12 continuous months of prior coverage, the waiting period can also be reduced by the number of months of prior coverage.

Participants who have been on the plan for less than one year and receive medical care may receive a letter asking for more information before the claim can be processed. This letter is not necessarily a denial of coverage, but an attempt to gather more information so that the claim can be processed. This letter asks the participant to either obtain the Certificate of Creditable Coverage or to sign a release from the participant so that the plan may determine whether or not the care provided was for a pre-existing condition. When a participant receives this letter, the best option is to obtain their Certificate of Creditable Coverage for prior coverage and then send it to the address in the letter. Once the certificate is on file with the claims administrator there will be no need to investigate future claims (provided that the prior coverage qualifies and was for one full year of prior coverage).

If the participant does not have creditable coverage, but feels as though the claim is not a pre-existing condition, the participant should sign the release and return it to the claims administrator. The claims administrator will verify that the condition is not pre-existing with the provider and process the claim. If a claim does meet the pre-existing condition definition and the participant does not have prior coverage, then coverage under the plan will not be available. Once a participant has been on the A-Plus Benefits plan for one full year, then the waiting period has been met and claims will not be reviewed for the pre-existing condition exclusion.

The preceding information is intended to be an aid to health plan participants. It does not supersede or replace information contained in the Master Plan Description. All of the limits, requirements, and exclusions detailed in the Master Plan Description will apply.

Steve Anderson is the Benefits Manager for A Plus Benefits, Inc.